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Year: 2019

Randomized clinical trial on indirect resin composite and ceramic laminate

veneers: Up to 10-year findings

Gresnigt, M M M ; Cune, M S ; Jansen, K ; van der Made, S A M ; Özcan, M

Abstract: OBJECTIVES In this randomized split-mouth clinical trial the survival rate and quality of
survival of indirect resin composite and ceramic laminate veneers were evaluated. METHODS A total
of 48 indirect resin composite (Estenia; n = 24) and ceramic laminate veneers (IPS Empress Esthetic; n
= 24) were placed on maxillary anterior teeth. Veneer preparations with incisal overlap were performed
using a mock up technique. Survival of the restoration was considered the primary outcome measure and
reported using Kaplan-Meier statistics and survival curves compared by means of Log Rank (Mantel-
Cox) test. After luting, restorations were evaluated by calibrated operators at baseline and every year
thereafter, using modified USPHS criteria and compared by means of Mann-Whitney U test. RESULTS
In total, 6 failures were observed, consisting of debonding (n = 3) and fracture (n = 3), all in the
group of the indirect resin composite laminate veneers. Cumulative chance on survival after 10 years
of the indirect resin composite and ceramic veneers was 75% (se 3,8%) and 100% respectively (p =
0.013). Of the surviving 42 laminate veneers, the variables ’color match’ (p = 0.002), ’surface roughness’
(p = 0.000), ’fracture of the restoration’ (p = 0.028), and ’wear of the restoration’ (p = 0.014), were
significantly less favourable among the composite laminate veneers as well. CONCLUSIONS The ceramic
veneers on maxillary anterior teeth in this study performed significantly better compared to the composite
indirect laminate veneers after a decade, both in terms of survival rate and in terms of quality of the
surviving restorations. CLINICAL RELEVANCE When indicated, anterior ceramic laminate veneers
may be preferred over indirect composite laminate veneers.

DOI: https://doi.org/10.1016/j.jdent.2019.06.001

Posted at the Zurich Open Repository and Archive, University of Zurich

ZORA URL: https://doi.org/10.5167/uzh-183287
Journal Article
Accepted Version

The following work is licensed under a Creative Commons: Attribution-NonCommercial-NoDerivatives

4.0 International (CC BY-NC-ND 4.0) License.

Originally published at:

Gresnigt, M M M; Cune, M S; Jansen, K; van der Made, S A M; Özcan, M (2019). Randomized
clinical trial on indirect resin composite and ceramic laminate veneers: Up to 10-year findings. Journal
of Dentistry, 86:102-109.
DOI: https://doi.org/10.1016/j.jdent.2019.06.001
 Randomized Clinical Trial on Indirect Resin Composite and Ceramic Laminate Veneers: Up

to 10-year Findings

M.M.M. Gresnigt1,2*, M.S. Cune1,3,4, K. Jansen1, S.A.M. van der Made5, M. Özcan6

1The University of Groningen, University Medical Center Groningen, Department of Restorative Dentistry and

Biomaterials, Center for Dentistry and Oral Hygiene, The Netherlands; 2Martini Hospital, Department of Special

Dental Care, Groningen, The Netherlands; 3St. Antonius Hospital, Department of Oral and Maxillofacial Surgery

and Special Dental Care, Nieuwegein, the Netherlands; 4University Medical Center Utrecht, department of Oral

and Maxillofacial Surgery and Special Dental Care, Utrecht, the Netherlands; 5Dental laboratory Kwalident,

Beilen, The Netherlands; 6University of Zurich, Center for Dental and Oral Medicine, Dental Materials Unit,

Clinic for Fixed and Removable Prosthodontics and Dental Materials Science, Zurich, Switzerland;

*corresponding author, marcogresnigt@yahoo.com

Short title: RCT on indirect composite and ceramic laminate veneers

*Corresponding author:

Marco Gresnigt, Department of Restorative Dentistry and Biomaterials, Center for Dentistry and Oral Hygiene,

University Medical Center Groningen, The University of Groningen, Antonius Deusinglaan 1, 9713 AV,

Groningen, The Netherlands, Tel: +31-6-47494611, E-mail address: marcogresnigt@yahoo.com.

KEY WORDS: adhesion, ceramic, clinical trial, indirect composite, laminate veneer, randomized

Acknowledgements

The authors extend their gratitude to Ivoclar Vivadent, Liechtenstein and Kuraray, Tokyo, Japan for

supplying some of the materials used in this study. There are no conflicts of interest.

1
Abstract

Objectives

In this randomized split-mouth clinical trial the survival rate and quality of survival of indirect resin

composite and ceramic laminate veneers were evaluated.

Methods

A total of 48 indirect resin composite (Estenia; n=24) and ceramic laminate veneers (IPS Empress

Esthetic; n=24) were placed on maxillary anterior teeth. Veneer preparations with incisal overlap were

performed using a mock up technique. Survival of the restoration was considered the primary outcome

measure and reported using Kaplan-Meier statistics and survival curves compared by means of Log

Rank (Mantel-Cox) test. After luting, restorations were evaluated by calibrated operators at baseline

and every year thereafter, using modified USPHS criteria and compared by means of Mann-Whitney

U test.

Results

In total, 6 failures were observed, consisting of debonding (n=3) and fracture (n=3), all in the group of

the indirect resin composite laminate veneers. Cumulative chance on survival after 10 years of the

indirect resin composite and ceramic veneers was 75% (se 3,8%) and 100% respectively (p=0.013).

Of the surviving 42 laminate veneers, the variables ‘color match’ (p=0.002), ‘surface roughness’

(p=0.000), ‘fracture of the restoration’ (p=0.028), and ‘wear of the restoration’ (p=0.014), were

significantly less favourable among the composite laminate veneers as well.

Conclusions

The ceramic veneers on maxillary anterior teeth in this study performed significantly better compared

to the composite indirect laminate veneers after a decade, both in terms of survival rate and in terms

of quality of the surviving restorations.

Clinical Relevance

2
When indicated, anterior ceramic laminate veneers may be preferred over indirect composite laminate

veneers.

Clinical Trial Registration Number: NCT03145597

3
Introduction

Laminate veneer restorations are indicated for different esthetic reasons as a minimal invasive

treatment concept. Based on the literature there is no consent as to which material should be used

as the restorative material, composite or ceramic [1,2]. Some attempts have been made to compare

these materials in vivo, however, no comparison was made in vivo in a split mouth environment with

over 8 years of follow up [1,3].

Survival rates of ceramic laminate veneers range between 82-96% after 10-21 years [4–9].

Fracture of ceramic material (5.6-11%) and marginal defects (12-20%) were the main reasons of

failure [4,6,10–14]. Success rates are reported to decrease due to poor marginal quality and

discoloration which contained 18-25% up to 10 years of function.

Indirect composite restorations are easy to cement and repair, have higher flexural modulus, are

cost effective and less abrasive to the antagonistic teeth [15]. Contemporary particulate filler

composites (Estenia, Kuraray Co., Tokyo, Japan) contains up to 92 weight% colloidal silica spheres

with 16 weight% superfine microfillers, grain size of 0.02 µm, and 76 weight% microfillers, grain size

of 2 µm in urethane tetramethacrylate (UTMA) resin matrix. Previous indirect composite resin

materials contained merely 50-80 weight% of fillers [16,17]. In addition, UTMA resin matrix which

contains four functional urethane methacrylates resulting in a higher crosslinking density than other

materials [17]. The higher filler content increases both strength and optical properties, but make the

material more brittle as well.

Direct comparison between different material options for laminate veneers were only performed in

few studies with relatively short follow-up periods. Therefore, the Cochrane Collaboration concluded

that there is no evidence as to which material performs better [2]. In an in vivo study by Meijering et

al. [1] different materials were compared for laminate veneers; direct composite, indirect composite

and ceramic. Survival rates were 6%, 13% and 0% respectively after a mean follow up period of 1.7

years. Relative failures were not different among the indirect composite and ceramic restorations. In

4
a split mouth randomised clinical trial with 3 years of follow up similar failure rates were obtained for

indirect resin composite laminate veneers (13%) [3]. Relative failures were seen but not considered

significant between the two materials either, except for surface roughness [3].

Due to aging of dental materials, differences between materials could be expected. Exposure to

smoking, food, acidic beverages, temperature changes, function of the teeth, saliva and biofilm will

affect various materials differently. Although composite materials are known for their degradation,

ceramic or the glaze layer of the ceramic will also deteriorate over time due to acidic influences and

functional wear [18,19]. Degradation of the surface polish or smoothness will not only affect the

esthetic appearance, but also biofilm accumulation [20] and wear of surrounding or opposing teeth

[21–23].

The objective of this randomized clinical trial was to evaluate the clinical performance of maxillary

anterior laminate veneers made of particulate filled composite and ceramic in a split-mouth design

after a mean observation period exceeding 8 years of clinical service. Primary outcome parameter

was survival of the restoration, secondary outcome parameter was the quality of survival. The null

hypothesis tested was that both laminate materials would function similarly.

Materials and Methods

Study Design

This is the follow up study of data presented in our previous article.[3] To avoid possible disturbing

differences in case when distinct degrees of tooth discoloration would occur between restorations of

different materials, a modified split mouth design was employed in which the central incisors and the

symmetrical other teeth received the same type of restoration. Randomization was performed using

the flip of a coin for the choice of material. For this observational study the STROBE guidelines were

followed.

5
Inclusion and Exclusion Criteria

Potential candidates were at least 18 years old, able to read and sign the informed consent document,

physically and psychologically able to tolerate conventional restorative procedures, having no high

caries risk, periodontal or pulpal diseases, having teeth with good restorations, require esthetic

improvement of at least 2 anterior teeth, not allergic to resin-based materials, not pregnant or nursing,

and willing to return for follow-up examinations as outlined by the investigators. Between June-2008

and November-2010, a total of 11 patients ranging in age between 20 and 69 years (8 female, 3 male,

mean age: 54.5 years) could be recruited and received 48 indirect composite (n=24) and ceramic

laminate veneers (n=24). Alternative treatment options were discussed. All patients provided informed

consent as required by the ethical committee of the University Medical Centre Groningen review board

(Clinical Trial identification number: NCT03145597).

Tooth preparation

Treatment planning was performed using digital photos, and stone casts. Shade was determined

using different shade tabs under standard conditions (6500 K, 8 light intensity, Longlife, Aura, The

Netherlands) in the dental laboratory. A wax set-up was made on the plaster model using the mock-

up technique [9]. The wax set-up was used to communicate on the correction of the form and position

of the teeth and also to evaluate the expectations of the patient.

Magnifying microscope (x3.4 - 21.3) (Opmipico, Zeiss, Sliedrecht, The Netherlands) was used for

minimal preparations. Ball-shaped diamond burs (ISO 801 018, Diatech, Altstätten, Switzerland) were

used to mark preparation depths through the set-up. The labial surfaces were axially reduced by 0.3-

0.5 mm. Tapered round-ended diamond burs (ISO 856 018, Diatech) were used for uniform

preparations. An incisal overlap of 1-1.5 mm was prepared on all cases. At the cervical area, a shallow

chamfer finish line (0.5 mm) was created equi- or supra-gingival to maintain good periodontal health.

6
A shallow chamfered marginal finish line extended inter-proximally to hide the restoration margins up

to contact area.

All internal angles were smoothed to reduce stress concentration. On the palatal aspect, a right-

angled contour (butt joint) between the incisal edge and the palatal surface was achieved.

Impressions were then made using a polyether impression material (Impregum, 3M ESPE, St. Paul,

MN, USA). Temporary veneers were made chair-side using a spot-etch technique and auto-

polymerized bis-acryl (Structur SC, Voco, Cuxhaven, Germany).

One dental technician made all laminate veneers. Leucite reinforced glass ceramic (IPS Empress

Esthetic, Ivoclar Vivadent, Schaan, Liechtenstein) were processed according to the manufacturer’s

instructions using the IPS Empress layering and lost wax technique. After wax-up, a cut-back of 0.2-

0.8 mm was performed to allow for layering of the veneering ceramic.

The indirect composite laminate veneers (Estenia C&B, Kuraray, Tokyo, Japan) were fabricated

using the layering technique following the manufacturer`s instructions. They were heat- (100-110°C

for 15 min) and photo-polymerized (400-515 nm for 270 seconds) using a special polymerization

device (Heat-curing-110, Toesco, Yoshida, Japan) according to the manufacturer’s

recommendations.

Both ceramic and resin composite laminate veneers were hand polished using diamond burs and

silicone rubber points (3044HP-30044HP Ceragloss, Edenta, St. Gallen, Switzerland) and diamond

pastes with brushes (Estenia C&B polishing compound and Yeti Diaglaze).

Luting

Form, adaptation and shade match of the restorations were checked clinically using try-in pastes

(Variolink Veneer Try-in Paste, Ivoclar Vivadent).

After cleaning with 99% isopropanol, intaglio surfaces of the laminates were etched with 4.9%

hydrofluoric acid (IPS Ceramic etching gel, Ivoclar Vivadent) for 1 minute, washed thoroughly for 1

minute and dried with oil-free compressed air. Since etching with hydrofluoric acid leaves a significant

7
amount of crystalline debris precipitate at the ceramic surface,4 laminate veneers were ultrasonically

cleaned in distilled water for 5 minutes. Thereafter, the adhesive surfaces were silanized (Monobond

S, Ivoclar Vivadent) for 1 minute. After silanization, adhesive resin (ExciTE, Ivoclar Vivadent) was

applied, air-thinned but not polymerized.

The intaglio of the indirect composite laminate veneers was tribochemically silica coated (30 µm

SiO2, CoJet-Sand, 3M ESPE) using an intraoral air-abrasion device (Dento-Prep, RØNVIG A/S,

Daugaard, Denmark) at a pressure of 2.5 bar from a distance of approximately 10 mm for 20 seconds.

They were then silanized with 3-methacryloxypropyltrimethoxy silane coupling agent (MPS) (ESPE-

Sil, 3M ESPE AG) and waited for its evaporation for 5 minutes. After silanization, adhesive resin

(ExciTE, Ivoclar Vivadent) was applied, air-thinned but not polymerized.

All teeth to be veneered were isolated using a split-rubberdam technique. Contour strips (Contour-

Strip, Ivoclar Vivadent) were placed interproximal to perform a smooth restoration outline in the

approximal-cervical area. The prepared teeth were first cleaned with fluoride-fee pumice (Pumice

Flour, Dux, Utrecht, The Netherlands) using a polishing brush (Polishing brush, Coltène/Whaledent,

Altstatten, Switzerland).

Enamel and dentin were etched with 37% H3PO4 (Total Etch, Ivoclar Vivadent, Schaan,

Liechtenstein) for 15-30 seconds. After rinsing for 30 seconds and air-drying, the adhesive resin

(ExciTE, Ivoclar Vivadent) was then applied on both the tooth and the restoration surfaces with a

microbrush for 15 seconds, air-thinned but not polymerized.

Laminate veneers were luted using a photo-polymerizing resin composite cement (Variolink Veneer,

Ivoclar Vivadent). Composite was applied to the inner surface of the laminates. After placement,

initially, they were photo-polymerized with an LED lamp (Bluephase 20i, Ivoclar Vivadent) for only 3

s at the buccal surface to ensure stabilization of the veneer. The light output was at least 800 mW/cm2

in all applications. Gross excess composite at the margins was removed immediately with the aid of

brushes, scalers and dental floss (Oral-B, Rotterdam, The Netherlands). Application of glycerine gel

8
(Liquid-Strip, Ivoclar Vivadent) at the margins ensured oxygen inhibition during polymerization.

Buccal, oral, and proximal surfaces were further polymerized for 40 s. After rinsing the glycerine gel,

excess material was removed with hand-instruments and finishing burs. Restoration margins were

further polished with silicone polishers (Astropol FP, HP, Ivoclar Vivadent) and interproximal polishing

strips (Soft-Lex Finishing Strips, 3M ESPE) at 7.500-10.000 rpm under water. One clinician placed all

restorations. Finally, the occlusion was checked in protrusive and lateral movements of the mandible.

The goal was to reach anterior guidance and lateral protection in all cases. Patients were given

information on how to clean the restorations and teeth, on diet (no restrictions with food or drinks), no

nail biting and parafunctional habits (providing a night guard).

Evaluation

Restorations were clinically evaluated at baseline and thereafter by two calibrated observers who

were blinded to the objective of this study. Caries, debonding and fracture to failure were considered

as absolute failures. Patients were also questioned about possible post-operative complaints. Both

observers evaluated the restorations independently, according to the modified United States Public

Health Service (USPHS) criteria (Table 1). The restorations were visually inspected with dental mirror

and probe. After data collection, in case of discrepancies in scoring, restorations were evaluated

again, a consensus was reached and this was accepted as the final score. Patients were instructed

to call upon any kind of failure. Digital pictures (1:1) were made after placement of the veneers and

during follow-up sessions. In representative cases, an impression (Ultra-Light and Heavy body

Aquasil, Dentsply) was taken from the two laminate veneers after cleansing the surface with

absorbent paper and sodium hypochlorite 0.5%. Impressions were poured with cold mounting epoxy

resin (Epoxy-Cure, Buehler, IL, USA) then sputter-coated with a 3 nm thick layer of gold (80%) /

palladium (20%) (90 s, 45mA; Balzers SCD 030, Balzers, Liechtenstein) and analyzed using cold field

9
emission Scanning Electron Microscope (SEM) (LyraTC, Tescan, Brno, Czech Republic). Images

were made at 15 kV at a magnification of x22 to x2.500.

Statistical Analysis

Survival analyses were performed with statistical software program (SPSS 23.0; SPSS Inc, Chicago,

IL, USA) using Kaplan-Meier and Log Rank (Mantel-Cox) tests to obtain the overall survival rate in

relation to observation time. A nonparametric test (Mann-Whitney U test) was performed for the

qualitative evaluation of the data. An alpha level of 0.05 for all statistical tests was set.

Results

5 Recalls were performed after baseline measurements and no drop-outs occurred, yielding to the

evaluation of 48 indirect laminate veneers (Estenia: n=24; IPS Empress Esthetic: n=24). After

including 11 patients, it was decided to stop the further inclusion of patients due to failures and

differences seen in longevity between both groups. The mean observation time was 97 months with

a minimum observation period of 89 months (n=4) and up to a maximum of 120 months (n=4). The

distribution of the location of the restorations was as follows: 20 on central incisors, 18 on lateral

incisors, and 10 on canines. Average treatment time for each restoration was noted to be

approximately 120 minutes, regardless the treatment type. Two patients received occlusal splints after

cementation, indicated because of parafunctional habits.

The cumulative chance of survival was 75% (se 3,8%) and 100% for the indirect composite land

ceramic laminate veneers respectively after 10 years (120 months). Survival curves showed a

statistically different distribution (p=0.013) [Kaplan-Meier, Log Rank (Mantel-Cox) (Cl=95%)] (Fig. 2).

A total of 6 absolute failures were observed, all in the in the group of the indirect resin composite

veneers in the form of debonding (n=3) or fracture (n=3). The debondings were a complete adhesive

failure between the tooth and the luting cement, which occurred 11 to 25 months after cementation.

Some of the composite remained attached to the inner surface of the laminate restoration. After

10
cleaning the adhesive surface, the debonded veneers were re-bonded but were not further evaluated

and scored as a failure. All ractures occurred at the incisal area and were cohesive failures in the

indirect composite material. The first fracture occurred on a tooth 11 (figure 5a), 13 months after

delivery. The second laminate fracture occurred on a tooth 22 which was sound, 11 months after

delivery. The third fracture occurred 6 years after placement after eating some bread.

Besides absolute failures, success was scored using the USPHS criteria (table 2). Qualitative

evaluation (success) showed some significance differences between laminates made of ceramic and

indirect composite (Table 2). For all of these variables, the ceramic restorations were rated better. Of

the 42 laminate veneers, minor voids and marginal discrepancies and defects were observed in 14 of

the composite and 10 of the ceramic veneers (Adaptation-Score 1-2). Color match was significantly

(Mann-Whitney U = 324, p=0.002)different as the ceramic laminate veneers matched the surrounded

teeth, composite restorations did not match for 8 laminate veneers (p=0.002). Slight staining at the

margins was seen more frequent with the composite laminate veneers (n=12), however not significant

(p=0.107). Slightly rough surfaces (Surface roughness-Score 1) were significantly (Mann-Whitney U

= 444, p=0.000) more observed in the resin composite laminate veneer group (n=18) until the final

recall. These rough surfaces also experienced more plaque adhesion (figure 4b). Internal fractures

without intervention were significantly (Mann-Whitney U = 292, p=0.028) more seen (n=6, p=0.028)

in the indirect composite group, chippings of tooth material were more seen in the composite group

as well however this was not significant different (p=0.06). Wear of the restoration was significantly

(Mann-Whitney U = 303, p=0.014) more seen in the indirect composite group (n=7, p=0.014).

Secondary caries, endodontic complications or wear of the antagonist were not observed in any of

the cases. In total, 8 teeth showed post-operative sensitivity at baseline, as reported by the patient.

All post-operative sensitivities disappeared after 2 weeks; at the final recall 2 teeth were somewhat

sensitive to cold. SEM and digital pictures were used for surface evaluation as can be seen in figure

3. This particular patient had her laminate veneers for 9 years and differences in surface change

11
between the two materials can be clearly seen. Gloss retention was better with the ceramic

restorations which is also seen at the SEM analysis. Patients were not aware of the loss of gloss due

to saliva over the restorative materials (figure 4a-b).

Discussion

In this randomized split mouth clinical trial, a comparison of indirect resin composite and ceramic

laminate veneers was performed. This is the first clinical trial on anterior indirect restorations using

two different restorative materials with a mean follow up of more than 8 years. The split mouth study

design used removes a lot of inter-individual variability from the estimates of the treatment effect. The

results presented cover observations up to 120 months of clinical function. In total 90% of the

laminates required no intervention which could be considered as clinically acceptable. However,

based on the significant differences in different aspects of success as well as the differences in

survival rates the null hypothesis that there is no difference between the two restorative materials was

rejected. Ceramic veneers performed significant better than the indirect composite ones.

Six absolute failures occurred in this study of which 3 failed within the first 13 months of the study.

The first failure occurred within the first year following luting and was a delamination of a composite

laminate veneer on a canine where the substrate was predominantly dentin. In the literature, it is

suggested that laminates bonded to large surfaces of dentin have a compromised survival rate and

in such a situation requires an immediate dentin sealing, which was not performed in our study [24–

26]. Increased fractures and chippings were noticed up to 8 times in studies where laminate veneers

were made in patients with bruxing habits [7,27]. In this study, instructions to the patients were given

at insertion of the laminate veneers regarding habits like nail biting and tearing materials with teeth.

Two patients were provided with a hard acrylic resin occlusal appliance as they were suspected

nocturnal bruxers. Patients were informed that there was a risk of fracture if compliance was

inadequate. Another fracture after 12 months of insertion is probably related to function during

12
protrusive and lateral excursive movements over teeth. Two debondings of composite laminate

veneers occurred in the same patient (25 months after insertion) where both central incisors had

reveived endodontic treatment prior to our study and the substrate was predominantly dentin again.

All debonded laminate veneers could be rebonded to freshly cut dentin removing only 0.1mm of

dentin, performing a three step dentin bonding adhesive (Optibond FL, Kerr, Orange USA) and using

a direct resin composite (HFO, Micerium, Avegno, Italy) as a cement [28,29]. All laminate veneers

functioned until the end of the study but were scored as failure and were not screened for follow up

evaluations.

Of the qualitative evaluation, most frequently observed differences were the surface degradation

and diminished gloss retention of the indirect resin composite material. All ceramic restorations

remained smooth and their gloss until the final follow up. Both materials were processed in the

laboratory and manufactured following the manufacturers’ instructions by an experienced dental

technician. The indirect composite material was photo- and heat-polymerized and both indirect

materials were hand polished. Increased degradation of the material itself was more prone with the

indirect composite material as is seen in other laboratory and clinical studies [30–33]. Fractures,

chippings and wear were frequently seen at the incisal palatal aspect. This could be related to function

and antagonist teeth articulating over these margin-material surfaces. One internal fracture in a

ceramic laminate veneer was observed in the second year of function. This fracture was not treated

or removed, but evaluated and remained stable until the end of the study.

Marginal quality was evaluated as adaptation of the veneer and discoloration of the margin. In

different studies on ceramic laminate veneers as well as our study these were the mostly observed

(adaptation: 56%; discoloration: 44%) qualitative complications [7,8,25,27,34,35] wear or degradation

of the luting composite in the margins leads to discolorations but no caries was observed in any of

the patients. Degradation of the margins was mostly observed in the palatal aspect and sometimes

when the cervical outline was in dentin on the cervico-buccal aspect. Most of the marginal

13
discolorations could be removed by polishing, however this was not performed as patients did not

complain and further experimental evaluation could be performed.

Evaluation of surrounding tissues did not show significant differences in gingival health between the

two materials. Only one patient had 0.5mm of recession at a central incisor (ceramic) and a lateral

incisor (indirect composite), which was probably related to brushing method and not to material

properties.

When absolute failures are considered, the clinical performance of indirect resin composite and

ceramic laminate veneers performed better up to 120 months. This finding is different from the first

article which only had data up to 3 years with a mean observation time of 20.3 months.[3] Surface

quality changes were more frequently observed in the composite veneer material that may require

more maintenance over time.

In conclusion, the ceramic veneers on maxillary anterior teeth in this study performed significantly

better compared to the composite indirect laminate veneers after a decade, both in terms of survival

rate and in terms of quality of the surviving restorations.

Compliance with Ethical Standards

Conflict of Interest: All authors declares that they have no conflict of interest.

Funding: The work was supported by the Department of Oral Function and Biomaterials, University

Medical Center, Groningen, the Netherlands.

Ethical approval: All procedures performed in studies involving human participants were in

accordance with the ethical standards of the institutional and/or national research committee and with

the 1964 Helsinki declaration and its later amendments or comparable ethical standards.

14
Informed consent: Informed consent was obtained from all individual participants included in the

study.

15
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Legends to figures and tables:

Figures:

Figure 1. CONSORT flowchart presenting the inclusion and exclusion criteria and the final

characteristics of the patients recruited to participate in this study.

Figure 2. Event-free survival rates of indirect resin composite and ceramic laminate veneers based

on material up to 120 months (Estenia: 75% (se 3,8%); n=24, events n=6; IPS Empress Esthetic:

100%; n=24, events n=0).

Figure 3a-d. Example of a representative patient at 9 year follow up recall. A) The intra oral situation

where the two central incisors are made of indirect composite and the laterals of ceramic. It can be

clearly seen that the central incisors did not keep their gloss B) Overview of the central and lateral

incisor using SEM C) A 2500 times magnification of the composite laminate veneer where the

degradation can be clearly seen D) A 2500 times magnification of the ceramic surface where there is

almost no degradation of the surface and remains smooth.

Figure 4a-b. Patient after 1 and 5 years follow up A) Patient experienced a small chipping of tooth 11

after 1 year B) Patient after 5 years, note the difference in plaque adhesion and margin integrity

between de composite and ceramic.

Figure 5a-b. Patient after 5 years follow up A) Patient with saliva on the teeth where the difference

between composite and ceramic is not clearly noticable B) Patient with dried teeth where the

difference between composite and ceramic is clearly noticable.

Tables:

Table 1. List of modified United States Public Health Service (USPHS) criteria used for the clinical

evaluations of the laminate veneers.

Table 2. Summaries of USPHS evaluations at baseline and final follow-up.

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Tables:

Category Score Criteria

Adaptation 0 Smooth Margin
1 All margins closed or possess minor voids or defects (enamel exposed)
2 Obvious crevice at margin, dentin or base exposed
3 Debonded from one end
4 Debonded from both ends

Color match 0 Very good color match

1 Good color match
2 Slight mismatch in color or shade
3 Obvious mismatch, outside the normal range
4 Gross mismatch

Marginal Discoloration 0 No discoloration evident

1 Slight staining, can be polished away
2 Obvious staining, cannot be polished away
3 Gross staining

Surface roughness 0 Smooth surface

1 Slightly rough or pitted
2 Rough, cannot be refinished
3 Surface deeply pitted, irregular grooves

Fracture of restoration 0 No fracture

1 Minor crack lines over restoration
2 Minor chippings of restoration (1/4 of restoration)
3 Moderate chippings of restoration (1/2 of restoration)
4 Severe chippings (3/4 restoration)
5 Debonding of restoration

Fracture of tooth 0 No fracture of tooth

1 Minor crack lines in tooth
2 Minor chippings of tooth (1/4 of crown)
3 Moderate chippings of tooth (1/2 of crown)
4 Crown fracture near cementum enamel line
5 Crown-root fracture (extraction)
Wear of restoration 0 No wear
1 Wear

Wear of antagonist 0 No wear

1 Wear of antagonist

Caries 0 No evidence of caries continuous along the margin of the restoration

1 Caries evident continuous with the margin of he restoration

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 Postoperative 0 No symptoms
sensitivity 1 Slight sensitivity
2 Moderate sensitivity
3 Severe pain

Table 1. List of modified United States Public Health Service (USPHS) criteria used for the clinical evaluations of the
laminate veneers.

Criteria Baseline Final evaluation

Estenia IPS Esthetic Estenia IPS Esthetic
(n=24) (n=24) (n=18) (n=24)

Adaptation of 0 17 20 P=0.308 4 14 P=0.212

Restoration 1 6 4 10 10
2 1 - 4 -
3 - - - -
4 - - - -
Color Match 0 9 10 P=0.770 10 24 P=0.002*
1 15 14 3 -
2 - - 5 -
3 - - - -
4 - - - -
Marginal 0 24 24 P=1 6 17 P=0.107
Discoloration 1 - - 8 6
2 - - 4 1
3 - - - -
Surface Roughness 0 18 24 P=0.01* 0 24 P=0.000*
1 6 - 17 -
2 - - 1 -
3 - - - -
Fracture of 0 24 24 P=1 12 23 P=0.028*
Restoration 1 - - 3 1
2 - - 3 -
3 - - - -
4 - - - -
5 - - - -
Fracture of Tooth 0 24 24 P=1 15 24 P=0.060
1 - - - -
2 - - 3 -
3 - - - -
4 - - - -
5 - - - -
Wear of Restoration 0 24 24 P=1 11 23 P=0.014*
1 - - 7 1
Wear of Antagonist 0 24 24 P=1 18 24 P=1
1 - - - -
Caries 0 24 24 P=1 18 24 P=1
1 - - - -
Post-operative 0 18 22 P=0.125 17 23 P=1
Sensitivity 1 4 2 1 1
2 2 - - -
3 - - - -

Table 2. Summaries of USPHS evaluations at baseline and final follow-up.

21
 Figures:

Figure 1. CONSORT flowchart presenting the inclusion and exclusion criteria and the final characteristics
of the patients recruited to participate in this study.

Figure 2. Event-free survival rates of indirect resin composite and ceramic laminate veneers based on
material up to 120 months (Estenia: 75% (se 3,8%); n=24, events n=6; IPS Empress Esthetic: 100%; n=24,
events n=0).

22
 a b c d

Figure 3a-d. Example of a representative patient at 9 year follow up recall. A) The intra oral situation where
the two central incisors are made of indirect composite and the laterals of ceramic. It can be clearly seen
that the central incisors did not keep their gloss B) Overview of the central and lateral incisor using SEM C)
A 2500 times magnification of the composite laminate veneer where the degradation can be clearly seen D)
A 2500 times magnification of the ceramic surface where there is almost no degradation of the surface and
remains smooth.

a b
Figure 4a-b. Patient after 1 and 5 years follow up A) Patient experienced a small chipping of tooth 11 after
1 year B) Patient after 5 years, note the difference in plaque adhesion and margin integrity between de
composite and ceramic.

a b
Figure 5a-b. Patient after 5 years follow up A) Patient with saliva on the teeth where the difference
between composite and ceramic is not clearly noticable B) Patient with dried teeth where the difference
between composite and ceramic is clearly noticable.

23
24